Circumcision activists square off against thousands of years of tradition

Dr. Helen Salsbury, who performs about five circumcisions a month in her Pembroke Pines obstetrics office, lays down week-old Baby Emilio in the gingerbread-man-shaped indent of a white plastic board called a Circumstraint Newborn Immobilizer. Using its wide Velcro straps, she secures his wrists and knees so Emilio cannot move. No one wants him wiggling during this procedure.

Salsbury warns Emilio's mother about potential complications: hemorrhage, infection, and even, she says, "loss of the penis." A less confident practitioner might not admit her own mistakes, but Salsbury goes into detail about the three instances in her career when she thought she might have removed too much or too little skin. In all three cases, she says, she sent the baby to a pediatric urologist, who deemed the babies just fine. Emilio's mom nods calmly and confirms she wants the procedure.

Salsbury dips the baby's pacifier in a dish of sugar before placing it in his mouth. She inches her hands into surgical gloves. She opens his diaper.

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Earlier, in her office, Salsbury had said many doctors do not numb the baby's skin before performing the procedure, but she prides herself on using a local anesthetic called lidocaine. "I'm probably the longest lidocaine-using doctor in Broward County. Circumcision is a brutal surgery. If you treated an animal the way we treat babies, you would be arrested for animal cruelty. We never remove a mole or a lump without lidocaine." She said circumcision without something to numb the pain would be "like removing your lips — squeezing the skin of your lips with Vise-Grips and cutting across that squeezed area. Very tender."

With a thin needle, she injects the lidocaine above and below the baby's penis, into the dorsal penile nerve, noting he might later develop small bumps at the injection site.

Emilio howls. His chest heaves as he lets out a cry and hyperventilates. His mom presses the pacifier back into his mouth.

The lidocaine takes effect after a minute or so, and the baby calms. Operating slowly and explaining as she goes, Salsbury inserts a hemostat, which looks like a long, skinny pair of pliers, through the tiny opening of the baby's foreskin. With sweeping motions, she separates his foreskin from the glans, or tip, of his penis. Her tool pokes around under the surface of his skin like chopsticks beneath a balloon.

Then Salsbury picks up a Mogen clamp, a palm-size, stainless-steel device with two sharp edges that swing open and shut on a pivot. Salsbury calls it an "antique." She pulls the baby's foreskin up over the tip of his penis, like the neck of a turtleneck sweater pulled high up over someone's head, and pinches the clamp just above. With a scalpel, she cuts off the flap of foreskin and places it on a surgical tray.

She releases the clamp, wipes away a trickle of blood, and presses her index fingers on either side of the baby's penis. The tip pops out like a bright, shiny red bulb. "A perfect little boiled peanut," Salsbury says. She piles a mound of Vaseline inside the baby's diaper and closes it.

"You should see the operations I've done on my kitchen table," Salsbury joked in her office, explaining that circumcisions are no big deal. But she acknowledged that "people have strong opinions for or against."

Indeed. A highly publicized conflict in California last year gave momentum to a small but dedicated group of people — a group that has some of its loudest proponents in Florida — who see circumcision as genital mutilation, a medically unnecessary amputation that should never be imposed on children against their will.

Although the foreskin has been enjoying something of a comeback in recent years as the national circumcision rate has dropped, these activists — or "intactivists," as many proudly call themselves — have decades of tradition and a massive medical establishment against them. With circumcision considered compulsory in some religions and now being touted as a powerful tool in the fight against HIV, the procedure is not going to disappear anytime soon.

Still, armed with blogs, business cards, and newborn-size T-shirts that declare "anteater pride," the intactivists soldier on in evangelical fashion, out to save one baby penis at a time.

According to the Bible, Abraham was 99 years old and childless when God told him he would be the father of many nations. God required something in return: "This is My covenant that you shall observe between Me and you and your children after you, to circumcise your every male." God instructed that males should be circumcised on their eighth day of life and that the soul of any uncircumcised male "shall be cut off from his people; he hath broken My covenant."

It's that reference in the Book of Genesis that's largely responsible for circumcision's spread. Ancient Egyptian hieroglyphs indicate the practice has been around since at least 2400 BC, but Jews made it an essential religious ritual. Most Muslims also circumcise because it is part of a set of hygienic practices that Muhammad endorsed, alongside the clipping of nails and plucking of armpit hair. Though many Christians also circumcise, passages in the New Testament suggest it's not mandatory.

Circumcision is unique among medical procedures because it's frequently performed by people with no formal medical training — primarily by Jewish leaders called mohels. Missionaries have also been known to carry out the procedure — including, most famously, Tim Tebow, the Denver Broncos quarterback who performed them during a trip to the Philippines in 2008.

In the gentile world, circumcision grew in popularity during the Victorian era, when supporters claimed it could tame a man's sex drive and stop boys from masturbating. As modern medicine evolved, circumcisions were routinely performed in hospitals on newborns.

But the procedure has always had its opponents. Ancient Greeks and Romans found it barbaric. It never caught on in Latin America and went out of fashion in much of Europe as countries with national health care sought to save money and stopped funding them after World War II. The practice has been banned in some public hospitals in Australia, and last year the main medical association in the Netherlands declared it a "painful and harmful ritual" that violates children's rights.

In America, exact numbers are difficult to calculate because data is collected only on the number of circumcisions performed on newborns in hospitals, while many more babies have the procedure done in doctors' offices or religious ceremonies. Still, experts generally agree the total rate peaked in the '60s and '70s at about 85 percent. According to the National Hospital Discharge Survey, the rate of in-hospital circumcisions was 65 percent in 1980 and dropped to 56.1 in 2006.

In the United States, the anti-circumcision movement can be traced to a Florida man named Van Lewis. While in college — he attended Harvard for a year and played the conch shell in the band — he began to find circumcision absurd and cruel. He decided to "spend the rest of [his] life figuring out where this insanity came from." On December 17, 1970, police arrested him for protesting outside Tallahassee Memorial Hospital. Though Lewis went on to run a seafood business and a clam farm, his claim to fame was inspiring others to talk about what had previously been a nonissue. He died in 2010, but in a video uploaded to the Internet, he chastises the concept of "doctors chopping ends off of babies' penises."

Then in 1979, California nurse Marilyn Milos witnessed her first circumcision and found the procedure inhumane and the baby's cry unnatural and chilling. In 1985, she started NoCirc, the National Organization of Circumcision Information Resource Centers. But it wasn't until the Internet age that anti-circumcision activists could easily find one another. Other groups sprang up, and an actual movement coalesced.

Foremost, the anti-circumcision crowd believes boys should be able to decide what happens to their bodies — especially in the case of a medically unnecessary amputation. They have likened circumcision to female genital mutilation — the cutting of a girl's genitals to kill her libido or make her "clean" — which is practiced in parts of Africa and the Middle East but condemned by most developed nations.

Circumcision critics charge that most arguments for the procedure are based on flawed logic. The idea that a child should look like his father? Well, who goes around comparing penises with his dad? The notion that the child will be called an "anteater" in the locker room? They liken it to shame that used to be applied to other once-taboo customs such as interracial marriage. An online "intactivism shop" — where "only the prices are rounded off" — sells T-shirts and bumper stickers declaring "hooded warrior" and "anteater pride."

Not all intactivists have such a cute sense of humor. Some accuse doctors of having a financial motivation for performing circumcisions. There are websites that "out" celebrities as intact and villainize researchers who have publicly promoted circumcision. Some even go so far as to accuse individuals of circum-fetish — being sexually aroused by circumcision.

Last summer, intactivists in San Francisco scored a win when they collected enough petition signatures to get a measure on the ballot that would ask voters to ban infant circumcision. The victory backfired, however; the ballot measure was stricken by a judge. After a huge outcry — especially by Jews, who found the notion anti-Semitic — the state legislature came down forcefully, passing a law that prevents local municipalities from attempting to ban circumcision.

The legal smackdown blunted many anti-circumcision activists' hope for having the procedure banned. But the episode, and the national attention it received, invigorated local movements around the country. Now, activists say, their focus is on education and outreach.

Today there are numerous national and international anti-circumcision groups. In Florida, the Tampa Bay Area Intactivists demonstrated January 15 at All Children's Hospital. This March, for the 19th year, Cocoa Beach resident David Wilson will lead a national gathering at the Capitol in Washington, D.C., with his organization, the Stop Infant Circumcision Society. There is Internet chatter about activists traveling to Orlando February 26 to protest Tebow, who is scheduled to appear at a golf tournament that weekend.

Rebecca Wald, a South Florida mother of two who is also a writer and has a law degree, was profiled in newspapers around the world after she launched a website, beyondthebris.com, that questions the wisdom of circumcision, particularly as it relates to Judaism. "When I found out that I was pregnant with a son," she says, "circumcision was one of the parenting issues that I researched. And the more that I learned about the effects of circumcision, the more I disliked it."

The issue is often too emotional for a rational discussion, she laments. "It's very surprising to me how uninformed people are about circumcision — even men who have been circumcised. I don't like to use the word ignorant, but it's amazing how uninformed they are — and how willing they are to be uninformed."

In Miami, protesters rallied in September 2010 outside South Miami Hospital to support "Baby Mario" after he was circumcised against his mother's wishes. Vera Delgado filed a lawsuit over the incident, with her attorney, Spencer Aronfeld, accusing the doctor of battery. The hospital admitted that a consent form was misread. The case was settled, but terms were not disclosed.

Afterward, Aronfeld proposed a "Mario's Law" that would prevent hospitals from circumcising newborn boys unless medically necessary, thus creating a waiting period so parents would not feel pressure to circumcise. No politician would sponsor it.

Around the country, scores of patients have sued over botched circumcisions. The company that manufactured the Mogen clamp went out of business after the FDA received hundreds of complaints about it, and the company lost three multimillion-dollar lawsuits, including a $10.8 million judgment for a Florida boy who lost the head of his penis when it became trapped in the clamp. Mogens, however, are still available on eBay for less than $20.

Aronfeld suggests the anti-circumcision movement suffers from a perception that it's a fringe movement of hippies and weirdos. "They sort of need a national spokesperson," he says. So far, no celebrity has stepped up to be the anti-circumcision poster boy or girl, although it has gained occasional national attention. Penn and Teller dedicated an episode of their Showtime series Bullshit to debunking circumcision myths. The lead singer of Blood, Sweat & Tears recorded a song about his botched circumcision. And Howard Stern frequently tells his radio listeners that he thinks the practice should be outlawed.

Even though Aronfeld is Jewish, he says he was swayed by the Baby Mario case. "There are a lot of compelling arguments to be made that circumcisions are not appropriate in this day and age. I'm open to that, and there is a lot of credibility to it."

On a Sunday afternoon in December, guests pass through two sets of heavy gates to reach the tony community of Williams Island, near Aventura. They park their Mercedes-Benzes and BMWs by a mailbox decorated with blue balloons. Inside the waterfront home, Michael Andron, dressed in a yarmulke and shawl, prepares to perform a bris, also called a brit milah. He puts on surgical gloves and places an anesthetic spray on a table. He sets aside an empty chair, a nod to the prophet Elijah, who, because of his zeal in upholding the ritual of circumcision, is said to be present in angel form at every bris.

About 50 people stand in a living room, chitchatting and sipping drinks from the open bar. When he's ready, Andron leads a singing prayer in Hebrew. In a short processional, a baby boy, bundled in blankets and wearing a crocheted yarmulke, is carried into the room. He is passed to his seated grandfather and laid on a fluffy white pillow, to which he is then strapped with a soft leather belt. He sucks contentedly on his pacifier.

After a brief welcome, Andron gets down to business. He warns that the baby has many reasons to cry but says he'll be fine. "I'm worried about all of you." He instructs, "Talk quietly — and try to stay vertical." Guests oblige, and a hum of party chatter picks up. Some people turn their heads away. Some make nervous faces and tightly grip their wineglasses. At least three hold their iPads high in the air to film the action. Andron picks up his Mogen clamp and bends over the baby.

Andron's combination of religious gravitas and personal warmth make him a highly in-demand mohel. He's also a karate master, an energy healer, and a theater director. "I'm a Jewish Renaissance man," he says. "The stuff I do is pretty odd."

Expectant families usually book him through his website. The bris must occur on the baby's eighth day, and owing to the uncertainty of the birth date, Andron is almost always on call. Some weeks, he performs just a few procedures; other weeks, he'll do 20. "Considering how extreme this commandment is," he says, even barely observant Jews usually have a bris. Andron does not charge a fee; rather, families make a donation to him. He doesn't like to talk about money but says that on average, he gets $500. Today he has performed five of them, thus earning about $2,500.

Andron was raised Modern Orthodox in New York. Initially, his professional interests were in holistic healing, but while living in North Carolina, he witnessed a bris by a talented mohel. "The surgery was elegant, fast, clean, professional, and artistic," he says. He apprenticed and learned to do them himself. Mohels do not need to be licensed by the state; they are regulated only by local rabbinical boards. Andron says he can do in a few seconds what it takes surgeons 20 minutes to do.

Andron dismisses the anti-circumcision crowd as a "noisy minority." Jewish boys, he says, might be mocked for not being circumcised, and Jews need to be circumcised before being buried in Jewish cemeteries. At times, Andron has even been called to perform the grim task of circumcising a stillborn baby.

If God is omnipotent and omniscient, why would he make baby boys born imperfect and in need of a surgery at birth? Andron takes a moment to answer. "God wants us to be part of the creation... Creation is incomplete. God doesn't give it to us finished."

Back at the bris, the baby unleashes a piercing cry, breathes rapidly, and squawks like a parrot. But only for a moment. True to his word, Andron completes the procedure in seconds. The foreskin is set aside for the family. It is typically buried.

In a short speech, Andron announces the baby's Hebrew name: Jacob. This is his "user ID to get into Heaven. Today he begins his spiritual journey — who he is, why he's here, and what he came to accomplish."

Andron lights a candle, passes a glass of wine, and holds the baby in the air like a trophy. The little one has stopped crying and fallen asleep.

John D. Geisheker keeps a database of "foreskin-friendly" doctors. In some states, such as Iowa, there are none. As the executive director and general counsel for Doctors Opposing Circumcision, he spends a lot of time fielding calls from parents of intact babies. He also files complaints against doctors who forcibly retract infants' foreskins in a misguided effort to "clean" them. That creates a "wound," equivalent to breaking a girl's hymen, Geisheker says.

A native of New Zealand, where the circumcision rate is almost nil, he says he's stunned at how few doctors here know how to care for an intact penis and scoffs at the American notion "that boys have a birth defect."

Geisheker says his all-volunteer group is constantly waging intellectual war against circumcision proponents. The Doctors Opposing Circumcision website lays out medical arguments against circumcision: It removes 50 percent of the foreskin, including the most sensitive areas of the penis. The foreskin protects the penis from infections and keeps the tip of the penis soft and moist.

But the biggest hurdle to the anti-circumcision movement is research indicating that circumcision has a protective effect against sexually transmitted diseases, particularly HIV. And in that battle, it's a smattering of intactivists such as Geisheker going up against the World Health Organization, the Harvard School of Public Health, presidents Bush and Obama, Bill Gates, and Bono. Their weapons are studies and research; their battlefields are websites and medical journals.

Studies have indicated that circumcised men have lower rates of penile cancer and urinary tract infections. However, infections are easily treated with antibiotics, and penile cancer incidences are so low that Geisheker's group argues it's unethical to perform 100,000 circumcisions to possibly prevent one case of cancer. "A number of infants will die in the process, and many (200) will sustain significant, serious complications," the Doctors Opposing Circumcision website claims. "Nowhere else in medicine is this type of prevention practiced."

Proponents of circumcision often cite three clinical studies done in the past decade on adult males in Ken­ya, Uganda, and South Africa. The studies made headlines around the world with claims that men who were circumcised could reduce the risk of HIV infection from heterosexual sex by 53 to 60 percent.

Critics found many reasons to attack the studies: African men felt invincible after circumcision and mistakenly believed it made them immune to AIDS. Circumcised men in the studies still contracted AIDS. And it's far more cost-effective to use money on condoms instead of circumcision. One analysis said that "preventing one HIV infection via circumcision would cost an estimated $5,845 — more than 100 times the cost of preventing a single infection with condoms."

But the critics were drowned out. The three African studies have led to tens of millions of dollars being invested in a massive scale-up of circumcision throughout the African continent. Much of the funding comes from the Gates Foundation and U.S. taxpayers, via the President's Emergency Plan for AIDS Relief. Circumcision camps have popped up from Zimbabwe to South Africa to Botswana.

Geisheker says the Africa research shouldn't be used to justify circumcision of infants. This spring, however, a big announcement is expected that will likely thrust the matter into the national news again. The American Association of Pediatrics is widely considered the leading authority on medical matters related to children. In 1999, the organization announced there was insufficient data to recommend routine neonatal circumcision, a stance that was reaffirmed in 2005. In the ensuing years, 18 states' Medicaid programs have stopped funding it.

In 2007, the American Association of Pediatrics convened a task force of experts to revisit its stance yet again. Dr. Doug Diekema, a pediatrician who practices emergency medicine at Seattle Children's Hospital, is one of a dozen people on the task force. He says the panel's "work is 95 percent done." Their new official stance has been drafted, and he expects it to be released this spring.

Their verdict? "It's fair to say that there are much more clear medical benefits than there were at the time of the last report," Diekema says. "I expect that the academy will come out with a somewhat stronger statement" leaning in favor of circumcision. This could lead to renewed pressure for Medicaid and insurance companies to cover the procedure.

Diekema says that "hundreds of papers were reviewed and judged for their quality" — including the Africa studies and studies pointed out to him by the anti-circumcision camp. "I get huge mailings from them — FedEx boxes, summaries. I do look at it. I have a file of all of that. But I am not about to let them do the evaluation for me. They will cite all kinds of studies, which were frequently terrible and didn't prove anything because they were so methodologically flawed."

Diekema empathizes with people who are reluctant to circumcise, but he says people must compare the benefits and risks. He adds, "The reality is that this decision is largely made by parents for cultural reasons and not medical reasons. Most parents have already made a decision, most often based on how they want the little boy's penis to look."

Michael Dulin first heard about the emerging practice of foreskin restoration — through which men wear skin-stretching devices in an attempt to grow new foreskins — about four years ago. He joined an online group called the National Organization of Restoring Men (NORM) and began buying and testing various contraptions. "It's incredible what we have to go through to get back what was stolen from us," Dulin says during an interview in his Jupiter home.

So far, he has tried six devices, all of which are analog and use weight and/or tension to stretch the skin. They include: T-tape, a tape that is attached to the skin and pulled with an elastic band that wraps around the leg; Foreballs, surgical steel balls that use gravity and do not set off a metal detector; and the TLC Tugger, which attaches to the tip of the penis and pulls skin between two plastic cones (inventor Ron Low claims to have sold 10,000 of them).

Experiments have also led Dulin to a couple of homemade contraptions — one created by a friend in Canada and another he came up with himself using a tuba mouthpiece. So far, he says, the $89 DTR — dual tension restorer, made of a nylon plate, a silicone gripper, and rubber bands — "is just the best. It's comfortable, and I'm seeing progress."

Dulin is aware some people find his project extreme, but he says, "I don't care what the neighbors think. I'm at the point where I'm restoring, and I'm proud." He thinks it's absurd that the same people who would mock him for wanting his natural anatomy believe "it's OK to chop it off; that's perfectly normal."

Dulin was circumcised as a baby and grew to resent it as he aged. Once an exhibit designer at the Bronx Zoo and later a farmer, Dulin had three children and moved to Florida after a divorce. He is now a full-time sculptor. Although he used to focus on traditional subjects such as Greek gods, he recently began making sculptures of uncircumcised penises. "We've got to get people acclimated to the intact penis," he says. "People don't even understand what it is."

Though he has a slight frame and a gentle voice, Dulin says that speaking out is the key to advancing the movement. He has attended anti-circumcision conferences and travels to the annual protests in Washington. He even has business cards that say "Michael Dulin, intactivist" and advertise an anti-circumcision website. He passes them out to anyone who will listen.

"I was in Walmart, and I saw a woman who was obviously pregnant," he recalls. "I said, 'Excuse me, I don't know if you've considered circumcision or not, but may I give you this card?'" He says another woman at the DMV told him: "Thank you. I had no idea."

So far, Dulin says of his restoring process, "I'm seeing a little bit of wrinkling." Restorers have come up with an objective way to measure their progress, which they call the Circumcision Index. "I was a CI 1. Now I'm a CI 2. Ten is the best; it's what we're all striving for — full coverage with overhang. New foreskin coming to the tip of the penis."

He also has his sights set on some "space-age stuff." A Rome-based organization called Foregen is raising money — $20,700 so far toward its $200,000 goal — to use regenerative skin tissue to grow new foreskin. "If they can grow an ear on the back of a mouse, why not a foreskin?" Dulin asks. "This is what all of the restorers have been waiting for our whole lives — the ability to have this done."

The general populace, he hopes, will eventually come around and leave baby boys' penises alone, but "it's going to take a generation. It's a civil rights movement."